Myopia has reached epidemic proportions globally, affecting nearly half of the world’s population.1 Uncorrected refractive error remains one of the leading causes of visual impairment.2 Risks associated with high myopia include retinal detachment, myopic chorioretinal neovascularization, myopic choroidopathy, early onset cataract formation, and increased incidence of glaucoma.3
Growing demand for independence from spectacles and contact lenses is shaped by lifestyle preferences, activity limitations, and the ongoing costs of corrective wear. Together, these factors have driven increasing interest in refractive surgery, which has become an essential part of modern myopia management.4
The following review summarizes current surgical options, criteria for patient selection, and pearls for clinical management.
Surgical management of myopia
Surgical management for myopia broadly falls into two categories: cornea-based procedures and lens-based solutions.5
Corneal refractive surgery
Three types of corneal refractive surgery to treat myopia include:
- Laser-assisted in situ keratomileusis (LASIK)
- Photorefractive keratectomy (PRK)
- Laser-assisted lenticule extraction (LALEX)
LASIK
LASIK remains one of the most common surgical solutions for myopia. A femtosecond laser creates a ~90 to 120µm corneal flap, followed by excimer laser stromal ablation to reshape the cornea. Myopic ablations flatten the central cornea, while hyperopic ablations steepen the periphery.
An ideal candidate has stable refraction, no forme fruste keratoconus, a healthy ocular surface, and a residual stromal bed >250 to 300 µm. Large ablations in high myopia may increase higher-order aberrations and visual disturbances.
Advantages of LASIK include rapid recovery and minimal discomfort; while disadvantages include flap-related complications (e.g., dislocation, striae), and in very high myopia, the risk of optical side effects from higher-order aberration.6 Modern LASIK platforms use wavefront optimized, topography guided ablation, or ray tracing (e.g., Alcon Wave Light Plus) to minimize aberrations.
Complications are rare but can include surgical temporary ocular discomfort syndrome (STODS), LASIK-induced ectasia, epithelial ingrowth, diffuse lamellar keratitis (DLK), and infectious keratitis. STODS refers to a transient post-operative period of visual fluctuation, ocular surface dryness, and neuroadaptive discomfort following refractive or cataract surgery. It typically resolves once the ocular surface homeostasis is restored.
PRK
PRK involves epithelial removal (or epithelial flap in LASEK) followed by stromal excimer ablation. PRK may be a better option for patients with thinner corneas or surface irregularities (e.g., EBMD). While LASIK and PRK are both effective corneal refractive strategies, visual recovery is slower and post-operative discomfort is greater with PRK.
Risks of PRK include infectious keratitis and stromal haze, for which intra-operative mitomycin C can be used to reduce the risk. Stromal haze risk is increased with greater ablation depth. The risk of regression is higher in hyperopic ablations. Residual stromal depth thresholds similar to LASIK apply, but PRK may be preferable in thinner corneas.
In select off-label cases, combining PRK with corneal cross-linking (CXL) has been reported to treat both refractive error and stabilize ectatic corneas, per the Athens protocol.7
LALEX
LALEX, commonly known as small incision lenticule extraction (SMILE), uses a femtosecond laser (e.g., Zeiss VisuMax) to create and extract an intrastromal lenticule via a small incision (2 to 3mm). Advantages of LALEX include no flap creation and reduced post-operative dry eye syndrome.
The FDA-approved treatment range in the US is currently approximately -1.00 to 10.00D myopia (and up to ~3.00D astigmatism), with broader ranges internationally. Intra-operative complications include suction loss or incomplete lenticule removal. Refractive surprises may be managed with surface ablation, “cap-to-flap” conversion, thin-flap LASIK, or secondary SMILE in selected settings.8
Lens-based procedures to address myopia
Lens-based procedures offer effective refractive solutions for patients who are poor candidates for corneal laser surgery or who require correction beyond the limits of corneal-based approaches.
Phakic intraocular lenses (PIOLs)
Phakic IOLs are a preferred solution for moderate to high myopia or when corneal thickness or profile is inadequate for laser ablation.
Modern phakic IOLs (such as the EVO ICL by STAAR Surgical) are inserted in the sulcus, made of soft collamer material, and spare the cornea. Correct sizing is critical: white-to-white, anterior chamber depth, and sulcus-to-sulcus imaging (with ultrasound biomicroscopy [UBM]) have been supplemented with AI-based sizing tools (e.g., ICL Guru).
Vault refers to the space between the ICL and the crystalline lens and is an important factor to consider post-operatively. Low vault can be associated with anterior subcapsular cataract, while high vault can be associated with angle or IOP issues, such as transient intraocular pressure spike or glaucoma. An ideal vault is often cited as 250 to 750µm or ~0.5 to 1.5× central corneal thickness, though experienced surgeons may prefer a vault outside the above mentioned range in certain circumstances.5
EVO ICL can correct -3 to -16D with up to +3D of astigmatism at the spectacle plane. Toric ICLs are available for the correction of astigmatism; sizes commonly used for EVO ICLs range from 12.1 to 13.6mm.
Refractive lens exchange (RLE)
RLE involves removal of the crystalline lens and implantation of a premium IOL—addressing both refractive error and presbyopia. RLE is especially suited for presbyopes and short eyes at risk for angle closure glaucoma, as lens removal deepens the anterior chamber and can reduce IOP.
However, RLE eliminates the need for accommodation and carries risks similar to those of cataract surgery (e.g., retinal detachment, especially in high myopia). Age is an important factor for pre-operative consideration, as younger age has been shown to be associated with a higher risk of retinal detachment. Using the risk calculator for retinal detachment after cataract surgery can aid in pre-operative discussions.9
Tip: Setting expectations is especially important for RLE, as some patients may be more prone to positive dysphotopsias.
Developments and combined approaches in the surgical management of myopia
Hybrid strategies are increasingly common, particularly among high myopes who cannot achieve their refractive target with a single modality. For example, ICL implantation followed by LALEX or LASIK enhancement, or RLE followed by fine-tuning with LASIK or piggyback lenses.
Novel corneal additive techniques such as corneal tissue addition keratoplasty (CTAK) and corneal allogenic intrastromal ring segments (CAIRS) are emerging solutions for irregular astigmatism and mild to moderate keratoconus.9
Artificial intelligence and advanced ocular imaging are also streamlining patient selection, post-operative refractive prediction, and enhancement planning, offering increasingly individualized outcomes.10
Key takeaways
- Appropriate patient selection is paramount. Appropriate choice of technology and thorough pre-operative counseling regarding risks and benefits are indispensable to achieving ideal outcomes
- LASIK, PRK, and SMILE each offer effective cornea-based solutions for correcting refractive error, with the optimal procedure guided by corneal anatomy, topography, and patient-specific factors.
- Lens-based options expand surgical solutions for moderate to high myopia and presbyopic patients but require detailed counseling and meticulous sizing.
- Emerging hybrid and additive techniques expand the armamentarium and, when approached cautiously in the context of evidence and safety, may be exciting for patients who have historically had limited treatment options.
- Close co-management with optometrists enhances patient outcomes by setting realistic expectations and ensuring follow-up.
